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FOR OFFICE USE: .......... ........................ APPLICATI& FOR 5ANITAT)ON PERMIT .............. Permit NO. .7....1 ._.� ....................................................... .. (Complete in Triplicate) ~� . ,c ------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued .. ...— �. � Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ON .....?Z.. ...._.. .. .. ........ ... .... ......... ...CENSUS TRACT h Owner's Name ........ ............................................. ..Phone ............. Address .................91. .... Zv. _. AlCit ................... Contractor's Name .... 70 Im - -----rte: . . .. ............................License # 54,EM Phone i Installation will serve: Residence Apartment House❑ Commercial [-]Trailer Court ❑ E Motel Other ...........................•---••--- ....... Number of living units .. Number of bedrooms ----- Grinder _......_._.. Lot Size . .-l.._ao....... .__. Water Supply: Public System and name .................................•--.--------•••-----•••----•-•••-•---------•-•......-••-•---•--•........_._..Private ❑ Character of sail to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom 0 Clay Loam Hardpan 0 Adobe-❑ Fill Material ............ If yes,type ---------------------------- i. Mot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) i PACKAGE TREATMENT [ I SEPTIC TANK T ] Size... _ . ,/ .._ . . Liquid Depth . l° ............. Capacity . �1 Type .,, .......... Material-. l........ No. Compartments .._V1. .......... Distance to nearest: Well .....tath ...Foundation ... ---------- prop. Line . .�. .-----._..... LEACHING LINE [ ] No. of Lines .......0)........... Leofeach.line.._.-.�'�.............. Total Length . I� 'D' Box Type Filter Material ... Depth Filter Material ...... ..F........................... ' Distance to nearest: Well inundation Property Line 6K-P*GE j Depth . . ..gDiameter ................ Number ........ Rock Filled Yes 4 No Water Table Depth .................................................Rock Size ................................ I Distance to nearest: Well ........................................Foundation .................... Prop. Line ................ REPAIR/ADDITION(Prev. Sanitation Permit# ................_...---....---.............................. Date .................................. Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) ..--•--------••....................................................... ........................................................ ----------•--•-------------------------------- -•-•---•-- ................._.................----------------------------....... ...... L (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- ser! agents signature certifies the Following: x "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ....-,... -• --- --.. .. .. ... .... ---•--•-•---•- ....... Owner BY ............. rr�...._....... _,. ......-------•-------- Title ..---------•-------•-----..._..----..._._._............................. f o h t an wner) 9F2R D PARTMENT USE ONLY APPLICATION ACCEPTED BY ........ ---•• • •• - - -- ..................................................... DATE -----..... .....d _76..... BUILDING PERMIT ISSUED ..........................DATE .......... ....... ......... ADDITIONALCOMMENTS ..............................••-•-•------------------------------- -------------- --......---•-------------......------------•--------------.....-•-......... ................................................ Q f pr -- . ...... Final Inspection by: ...................�� .. . Date l._ . F ' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1-'68 Rev. 5M - - -_ - 7/723 ,%f -